Inspection Reports for
Heart of the Ozarks Healthcare Center
2004 CRESTVIEW ST, AVA, MO, 65608-8903
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
59% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 71
Deficiencies: 1
Date: Mar 25, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with nurse aide training and competency requirements, specifically to ensure nurse aides who have worked more than four months are trained and competent, and those who have worked less than four months are enrolled in appropriate training.
Findings
The facility failed to have a system in place to ensure nurse aides completed their training, competencies, and testing in a timely manner. Two nurse aides worked providing direct care without completing a state-approved certified nursing assistant training program, competency evaluation, and certification test within four months of hire.
Deficiencies (1)
Failure to ensure nurse aides completed state-approved CNA training, competency evaluation, and certification testing within four months of hire.
Report Facts
Census: 71
Days allowed for CNA training completion: 120
Hire date of NA A: Aug 28, 2024
Last day of NA A employment: Feb 16, 2025
Hire date of NA B: Sep 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding nurse aide training and scheduling |
| CNA Nursing Instructor | CNA Nursing Instructor | Interviewed about training classes and nurse aide progress |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about nurse aide training scheduling and instructor changes |
| Director of Nursing | Director of Nursing | Interviewed about nurse aide training referral and certification requirements |
| Administrator | Administrator | Interviewed about orientation, training oversight, and nurse aide certification compliance |
Inspection Report
Routine
Census: 81
Deficiencies: 6
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including medication administration, resident safety, weight management, medication error rates, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure clinically appropriate self-administration of medications, inconsistent documentation of residents' code status, inadequate monitoring and care planning for residents at risk of elopement, failure to timely identify and intervene in resident weight loss, medication administration errors exceeding acceptable rates, and failure to prevent serving food from dented cans.
Deficiencies (6)
Facility failed to ensure residents only self-administered medications if clinically appropriate; staff left medications in a resident's room without documented assessment or orders.
Facility failed to ensure a resident's choice of code status was clearly and consistently documented throughout the medical record.
Facility failed to care plan and monitor use of a personal electronic monitoring device for a resident at risk of elopement, and staff did not document required device checks.
Facility failed to timely identify and intervene in resident weight loss, failed to update care plans with new interventions, and failed to notify physician timely for one resident; also failed to notify physician timely for another resident's weight loss.
Facility failed to ensure medication error rate was less than 5% when two medication dosing errors occurred for two residents.
Facility failed to keep dented cans separate from other canned goods and served food from dented cans to residents.
Report Facts
Facility census: 81
Medication error rate: 7.69
Resident weight loss: 16
Resident weight loss: 20.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT G | Certified Medication Technician | Named in medication dosing errors for Residents #44 and #54 |
| ADON | Assistant Director of Nursing | Discussed medication order and administration errors |
| DON | Director of Nursing | Discussed medication errors, weight loss monitoring, and food safety |
| DM | Dietary Manager | Discussed resident weight loss and food safety issues |
| CNA D | Certified Nursing Assistant | Provided information on resident weight loss and meal assistance |
| RNA M | Restorative Nurse Aide | Reported resident weight loss and meal assistance |
| ST | Speech Therapist | Provided information on resident swallowing and eating behaviors |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: May 3, 2024
Visit Reason
The inspection was conducted due to a complaint regarding a staff member (Certified Medication Technician A) speaking to a resident (Resident #1) in an undignified manner, including raising his/her voice and arguing.
Complaint Details
The complaint was substantiated based on observations, staff interviews, and the facility's investigation. The incident involved CMT A making inappropriate comments and speaking disrespectfully to Resident #1, who had myasthenia gravis and required assistance with mobility.
Findings
The facility failed to ensure all residents were treated with dignity and respect by staff. Specifically, CMT A was observed arguing with Resident #1 in a loud, chastising voice and making inappropriate comments. The allegation was verified by staff interviews and observation.
Deficiencies (1)
Staff member spoke to resident in an undignified manner, including raising voice and arguing.
Report Facts
Census: 78
Sample size: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in undignified communication with resident finding |
| LPN B | Licensed Practical Nurse | Intervened in incident and reported to Director of Nursing |
| CNA C | Certified Nursing Assistant | Witnessed incident and intervened |
| CMT D | Certified Medication Technician | Provided interview supporting dignity and respect standards |
| DON | Director of Nursing | Provided interview on staff expectations for dignity and respect |
| Administrator | Administrator | Provided interview on staff expectations for dignity and respect |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 30, 2023
Visit Reason
Annual survey inspection of Heart of the Ozarks Healthcare Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
The document is an annual inspection report for Heart of the Ozarks Healthcare Center conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 78
Deficiencies: 7
Date: Nov 3, 2022
Visit Reason
Routine inspection to assess compliance with federal and state regulations regarding resident assessments, catheter care, respiratory care, food safety, equipment maintenance, and facility cleanliness.
Findings
The facility failed to complete timely annual and quarterly Minimum Data Set (MDS) assessments for multiple residents, lacked physician orders for catheter care for one resident, failed to administer ordered oxygen therapy to one resident, and had multiple food safety and sanitation deficiencies including a contaminated ice machine, wet stacked cups, unclean kitchen surfaces, missing stove knobs, and unsanitary kitchen floors and light fixtures.
Deficiencies (7)
Failed to complete an annual Minimum Data Set (MDS) assessment for one resident within the required timeframe.
Failed to complete quarterly MDS assessments for four residents within 14 days from the assessment reference date.
Failed to ensure physician's orders were obtained regarding placement and care of a catheter for one resident.
Failed to provide respiratory care as ordered by not administering supplemental oxygen to one resident.
Failed to ensure food was stored, prepared, and served in a manner that prevents contamination, including black substance in ice machine, wet stacked cups, and unclean food contact surfaces.
Failed to maintain kitchen equipment safely with nine stove knobs missing.
Failed to maintain a sanitary environment with dirty floors, ceiling tiles with lint, and light fixtures containing bugs in the kitchen area.
Report Facts
Facility census: 78
Number of residents with missing quarterly MDS assessments: 4
Number of residents with catheter order deficiencies: 1
Number of residents with oxygen therapy deficiencies: 1
Number of stove knobs missing: 9
Number of ceiling tiles with lint: 8
Number of bugs in light fixtures: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding MDS assessment completion delays | |
| Administrator | Interviewed regarding MDS assessments, catheter orders, oxygen therapy, and facility maintenance | |
| Director of Nursing (DON) | Interviewed regarding MDS assessments, catheter orders, oxygen therapy, and facility maintenance | |
| Licensed Practical Nurse (LPN) D | Licensed Practical Nurse | Interviewed regarding catheter orders and oxygen therapy monitoring |
| Registered Nurse (RN) E | Registered Nurse | Interviewed regarding catheter orders |
| Dietary Aide (DA) A | Dietary Aide | Interviewed regarding ice machine cleaning and kitchen sanitation |
| Dietary Aide (DA) B | Dietary Aide | Interviewed regarding ice machine cleaning and kitchen sanitation |
| Dietary Manager | Interviewed regarding kitchen cleaning schedules and equipment maintenance | |
| Maintenance Director | Interviewed regarding kitchen equipment and light fixture maintenance | |
| CNA F | Certified Nursing Assistant | Interviewed regarding oxygen therapy monitoring |
| CNA G | Certified Nursing Assistant | Interviewed regarding oxygen therapy monitoring |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 9
Date: Oct 22, 2019
Visit Reason
The inspection was conducted based on complaints and allegations regarding facility conditions, abuse reporting, bed hold policy, resident care, dialysis orders, infection control, and pest control.
Complaint Details
The visit was complaint-related, triggered by multiple allegations including facility disrepair, abuse reporting failures, bed hold policy noncompliance, inadequate resident care, dialysis order omissions, infection control lapses, and pest infestations. Substantiation status is not explicitly stated.
Findings
The facility was found to have multiple deficiencies including failure to maintain the building in good repair with water-stained ceiling tiles and roof leaks, failure to timely report and investigate suspected resident abuse, failure to provide written bed hold policy to residents upon hospital transfer, failure to timely report and treat skin issues, failure to have physician orders for dialysis specifying location and schedule, failure to properly conduct and document tuberculosis testing, failure to properly isolate and treat scabies cases, and failure to maintain an effective pest control program with ongoing roach infestations.
Deficiencies (9)
Facility failed to maintain a safe, clean, comfortable and homelike environment due to roof leaks and water-stained ceiling tiles.
Facility failed to timely report possible resident abuse to the state licensing agency for one resident.
Facility failed to complete an investigation of possible resident-to-resident abuse for one resident.
Facility failed to notify residents or their representatives in writing about bed hold policy upon hospital transfer for eight residents.
Facility failed to timely report and treat darkened areas on a resident's foot and failed to complete weekly skin assessments.
Facility failed to ensure physician's orders included dialysis location and schedule for three residents.
Facility failed to read and document tuberculosis test results in millimeters within required timeframe for five residents.
Facility failed to document isolation for one resident receiving scabies treatment, failed to provide timely scabies treatment for one resident, and failed to ensure staff followed proper infection control practices.
Facility failed to maintain an effective pest control program, resulting in ongoing roach and fly infestations throughout the building.
Report Facts
Facility census: 93
Roof replacement cost: 600000
Number of residents sampled: 19
Number of residents affected by bed hold policy deficiency: 8
Number of residents affected by dialysis order deficiency: 3
Number of residents affected by TB test documentation deficiency: 5
Number of residents affected by scabies treatment/isolation deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA S | Certified Nurse Aide | Named in scabies infection control finding; sent home due to rash and untreated scabies |
| RN M | Registered Nurse | Named in dialysis order deficiency and skin assessment findings |
| LPN P | Licensed Practical Nurse | Named in abuse reporting and dialysis order deficiency findings |
| Administrator | Named in roof repair, abuse reporting, bed hold policy, infection control, and pest control findings | |
| Director of Nursing | Named in abuse reporting, dialysis order, infection control, and pest control findings | |
| Maintenance Supervisor | Named in roof repair and pest control findings | |
| Housekeeping Staff V | Named in roof repair and pest control findings | |
| CNA R | Certified Nurse Aide | Named in skin assessment and scabies infection control findings |
| Corporate Nurse | Named in infection control and dialysis order findings | |
| Director of Operations | Named in dialysis order and pest control findings | |
| ADON K | Assistant Director of Nursing | Named in scabies infection control findings |
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